Transcript of "Child fatality report 2011"

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Department of Health & Mental Hygiene Michael R. Bloomberg Thomas Farley, M.D., M.P.H. Mayor Commissioner Dear Fellow New Yorker, Childhood injury deaths are tragic events that prematurely end the lives of young people each year. Keeping children safe from injury is a basic responsibility of families and communities. In 2006, to better understand unnatural deaths in children ages one to 12 years old and to identify strategies for injury prevention, New York City (NYC) established a multi- disciplinary Child Fatality Review Team (CFRT). This year’s report of the CFRT presents an updated examination of trends in child injury deaths, integrating an overview of nonfatal child injuries, and a review of sleep-related injury deaths among infants younger than one year old. This report presents multiple strategies to mitigate the circumstances that bring about fatal and serious injury among our City’s children and infants. Recommendations for the enforcement of select safety regulations, as well as the formulation of new regulations, are presented with attention to leading causes of child injury in NYC. Further, health care providers, parents and caregivers are given targeted guidance for creating safer environments for children. We hope this report will advance comprehensive childhood injury prevention among NYC children. Sincerely, Thomas Farley, M.D., M.P.H. Commissioner New York City Department of Health and Mental Hygieneii 2011 Child Fatality in New York City

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Key Findings1. etween 2001 and 2009, the overall death rate for children aged one to 12 years old was 30% lower B in New York City (NYC) than in the United States as a whole (between 2001 and 2007). Fewer injury deaths in NYC explain this difference. • e injury-related death rate among children in NYC was less than half the national rate (4 deaths per Th 100,000 compared with 8.7 deaths per 100,000). • e injury death rate due to accidents (also called unintentional injury) was two and a half times higher Th nationally than in NYC (7.1 deaths per 100,000 compared with 2.7 deaths per 100,000). This is mostly due to the difference in transportation deaths: 3.6 deaths per 100,000 children nationally compared with 1.2 deaths per 100,000 children in NYC.2. Injury deaths accounted for 28% of the 1,681 child deaths in NYC between 2001 and 2009. • ere were 470 injury deaths among children. The annual number of injury deaths varied with an average Th of 52 deaths per year. • nintentional injuries comprised 69% (n=324) of all child injury deaths. Of these, 41% (n=134) were U transportation-related. Of 116 motor vehicle accidents, 76% (n=88) involved child pedestrians. • ntentional injuries comprised 24% (n=114) of all child injury deaths. Of these, 91% (n=104) were I certified as homicides and 9% (n=10) as suicides.3. etween 2001 and 2009 higher injury death rates were found among younger children, boys and black, B non-Hispanic children. • ounger children had a higher injury death rate than older children (6.6 deaths per 100,000 children one Y to three years old vs. 3.3 deaths per 100,000 children 10 to 12 years old). • oys had a higher injury death rate than girls (4.5 vs. 3.4 deaths per 100,000). While 76% (n=207) of B fatal injuries among boys were due to unintentional injury compared with 59% (n=117) among girls, girls experienced a higher proportion of intentional injury deaths than boys (33%, n=64 vs. 18%, n=50) • e overall injury death rate among black, non-Hispanic children was about twice that of both white, Th non-Hispanic children and Hispanic children (6.2 per 100,000 vs. 3.3 per 100,000 white, non-Hispanic children and 3.1 per 100,000 Hispanic children). Black, non-Hispanic children and Hispanic children experienced a higher proportion of intentional injury deaths when compared with white, non-Hispanic children (30% and 29% vs. 6% of injury deaths, respectively).4. lthough nonfatal injuries among children aged one to 12 years are more common than fatal injuries, A the leading causes of nonfatal child injury hospitalization from 2001 to 2008 were similar to the leading causes of injury death. • n average, there were 3,895 nonfatal unintentional injury hospitalizations each year. Leading O contributors were falls (34%), burns (14%) and motor vehicle accidents (12%). • n average, there were 149 nonfatal intentional injury hospitalizations per year. Eighty-two percent O (82%) of these injuries were assault-related with child abuse (29%) and physical force (27%) as the leading contributors; 18% were from self-inflicted injury, with poisoning (61%) and cutting/piercing (17%) as the leading contributors.5. njury is also a leading cause of death among NYC infants (less than one year old); among injury deaths I more than three quarters (78%) of infant injury deaths are sleep-related. A review of all 252 sleep- related infant deaths from 2004 to 2008 shows that: • ore than half (57%) were found in an unsafe sleep position in bed; infants were on their stomach or on M their side rather than on their back. • Nearly two thirds (63%) were found bed-sharing with an adult or another child. • ore than three quarters (76%) were found on an unsafe sleep surface (an environment other than a crib M or bassinet); they were found in an adult bed, couch, stroller or car seat. • xcess bedding – defined as more bedding than a bed sheet and one blanket – was found in 64% E of sleep-related deaths. 2011 Child Fatality in New York City 1

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Glossary Accident – Injury or poisoning that occurred without intent to harm or cause death, also called unintentional injury. Asphyxia – A condition characterized by a lack of oxygen to the brain that results in loss of consciousness or unnatural death. Asphyxia can be the result of obstruction of airway (e.g., choking or drowning), compression of chest or neck, smothering, suffocation or inhalation of gas. Assault – A type of bodily harm committed by another person with the intent to cause fear, harm or death. Cause of death – The illness, disease or injury responsible for the death. Examples of natural causes include heart defects, asthma and cancer. Examples of injury-related causes include blunt impact, burns and drowning. Also known as mechanism. Child Fatality Review Team (CFRT) – A group of individuals representing a variety of agencies, organizations and disciplines who investigate preventable child deaths and make recommendations for policy and prevention. Death certificate – A legal document containing details of an individual’s death. Cause and manner of death and key demographic information are provided. Drowning – Death from asphyxia due to submersion in liquid, such as a large body of water, filled or partially filled pool, bathtub or household bucket. External causes of death – Death that is due to environmental events, poisonings or other adverse effects. Also known as unnatural death. They include injury-related causes of death and death due to complications of medical and surgical care. In this report, all child deaths due to external causes are referred to as injury deaths. Homicide – Death resulting from injuries committed by another person with the intent to cause fear, harm or death. Intentional injury – Injury resulting from the intentional use of force or purposeful action against oneself or others. Intentional injuries include interpersonal acts of violence intended to cause harm, criminal negligence or neglect (e.g., homicide) and self-inflicted (e.g., suicide). Manner of death – The circumstances of the death as determined by postmortem examination, death scene investigation, police reports, medical records or other reports. Manner of death categories include: natural, accident (unintentional), homicide (intentional), suicide (intentional), therapeutic complication and undetermined. Natural death – Death due solely to illness or disease. Non-transportation accident – A subcategory of unintentional injury that encompasses a variety of injuries not associated with any mode of transportation, such as falls, drownings and fires. Office of Chief Medical Examiner (OCME) – The office that investigates cases of persons who die within New York City from violence or criminal neglect, by accident, by suicide, suddenly when in apparent good health, when unattended by a physician, in a correctional facility, in any suspicious or unusual manner or where an application is made for a permit to cremate the body of a person. The OCME is responsible for postmortem examination, death scene investigation and final determination of cause and manner of death. Postmortem examination – External examination or autopsy used with other evidence to determine cause and manner of death. Self-inflicted injury – Injury from an intentional act with the intent to cause harm or death to oneself. Sleep-related death – A unique grouping of infant deaths caused by both injury (unintentional suffocation in bed and undetermined causes) and by sudden infant death syndrome (SIDS). Sudden Infant Death Syndrome (SIDS) – The sudden death of an infant less than one year of age, which remains unexplained after a thorough case investigation, including performance of a complete autopsy, examination of death scene and review of clinical history. SIDS is a natural cause of death and is not related to injury. Suicide – Fatality from an intentional, self-inflicted act with the intent to cause harm or death to self. Therapeutic complications – Death or injuries that result from causes associated with a medical or surgical intervention used to treat an illness or disease. Thermal injury – Fire, flame or scald burns due to contact with fire, hot surfaces, hot liquids or steam. Transportation accident – A subcategory of unintentional injuries in which the victim was a passenger in or injured by a motorized vehicle (e.g., car, plane or train). Undetermined – The classification of a death when all available information is insufficient to point to any one manner of death. In some cases, both cause and manner of death may remain undetermined. Unintentional injury – Injury that occurred without intent to harm or cause death; an injury not intended to happen. Also called an accident.2 2011 Child Fatality in New York City

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IntroductionIn New York City (NYC), and throughout the United States, injuries pose a threat to children’s health andwell-being and are the leading cause of child deaths, despite the fact that many injuries are predictable andcan be prevented through proven measures. Deaths from injuries are categorized as unintentional (such asdeaths caused by a motor vehicle accident, accidental suffocation or drowning) or intentional (such as injuriesfrom abuse and physical force). Through careful review of these child injury deaths we can identify specificopportunities to modify unsafe environments and prevent future deaths.The NYC Child Fatality Review Team (CFRT) was established in 2006 by Local Law 115 in response tothe need to better understand the unnatural or external causes of child deaths. The law mandates a review ofexternal causes of death of NYC children one to 12 years old. The CFRT published its first annual report in2007. The report included an aggregate review of child injury deaths and an in-depth case review of all childdeaths related to motor vehicle accidents, the leading cause of injury deaths among children in NYC. The2008 report focused on fire- and burn-related deaths, the second leading cause of child injury deaths inNYC. The 2009 report focused on setting and closely examined unintentional child injuries in the homeenvironment. Finally, the 2010 report focused on individual- and neighborhood-level disparities in child injurydeaths that reflect both social and economic inequalities. Viewed together, the first four CFRT reports providea comprehensive picture of trends in fatal injuries and their contributing factors among NYC children agedone to 12.For the 2011 CFRT report, we updated the statistics provided on child injury death with data from 2001to 2009. In addition, CFRT members elected to expand the report to include information on injury deathsamong infants less than one year old. This section includes a special focus on unsafe sleep-related deaths, asthey contribute to more than three quarters (78%) of injury deaths among this age group. A brief descriptionof nonfatal injuries among children and infants is also presented to provide a comprehensive picture of thetotal burden of severe injuries affecting NYC children under the age of thirteen. The final section of the reportpresents recommendations from the CFRT on preventing injuries among NYC children.BackgroundThe NYC CFRT is a multi-disciplinary review committee chaired by the Department of Health and MentalHygiene (DOHMH) and comprised of experts in child welfare and pediatrics appointed by the Mayor,City Council Speaker and Public Advocate, as well as representatives from several NYC agencies including:Administration for Children’s Services, Department of Education, DOHMH, Police Department and Officeof Chief Medical Examiner (OCME).The goals of the CFRT are to examine significant social, economic, cultural, safety and health-systems factorsassociated with external causes of death among children one to 12 years old to help identify modifiable riskfactors and to develop injury prevention policy and program recommendations.The CFRT meets quarterly to review aggregate data and identify trends and risk factors for injury-relateddeaths among NYC children aged one to 12 years. For this 2011 review, the CFRT invited representativesfrom the Consumer and Product Safety Commission, Department of Buildings, Department of HomelessServices, Department of Transportation and Housing Preservation and Development to participate inquarterly meetings. 2011 Child Fatality in New York City 3

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Methods Classification of Injury Deaths Among Children One to 12 Years Old Injury-related deaths were identified from death certificates maintained by the DOHMH Office of Vital Statistics. Cases were included in analyses if the manner of death on the death certificate was listed as an accident, homicide, suicide, undetermined or therapeutic complication, and the cause of death listed an International Classification of Disease, 10th Revision (ICD-10) code that was consistent with an unnatural, external cause of death. Death certificate data were verified and supplemented with additional information from files maintained by the OCME. These files contain autopsy or external examination reports, police and other investigative reports, toxicology and other postmortem special studies. Data abstraction was conducted using a form adapted from the National Center for Child Death Review Case Report. OCME files were not reviewed in cases pending criminal investigation, prosecution or appeal. The report utilizes conventional classification of injury deaths: Unintentional injury – An injury that was not deliberate, and occurred without intent to harm or cause death; an injury not intended to happen. This type of injury is described as accidental and includes: • Transportation accident – Fatal injury in which the victim was a passenger in or injured by a motorized vehicle (e.g., car, plane, train). • Non-transportation accident – Fatal injury caused by external factors such as falls, fires or drownings, and are not associated with any mode of transportation. Intentional injury – Injury resulting from intentional use of force or purposeful action against oneself or others. Types include: • Homicide – Fatality resulting from injuries sustained through an act of criminal negligence or violence committed by another person to cause fear, harm or death. • Suicide – Fatality from an intentional, self-inflicted act with the intent to cause harm or death to self. Undetermined – The classification of a death when all available information is insufficient to point to any one manner of death. In some cases, both cause and manner of death may remain undetermined. Therapeutic complication – Death or injury resulting from causes associated with a medical or surgical intervention (complication of medical and surgical care) used to treat an illness or disease. Though not the result of an injury, deaths from therapeutic complication are included in analyses because of their external nature. World Trade Center-related deaths were excluded from the report. For a complete listing of inclusion criteria and ICD-10 injury codes, please see the Technical Appendix. Classification of Nonfatal Injury Hospitalizations Among Children 0 to 12 Years Old Injury hospitalization data for all acute-stay hospitals in the five boroughs of NYC were acquired from electronic administrative files of the New York Statewide Program and Research Cooperative System (SPARCS), which is operated by the New York State Health Department. Only records of live hospital discharges from 2001 through 2008 were included in analyses. Injury hospitalizations were defined using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnostic codes and external cause of injury codes (E-Codes) according to a taxonomy similar to injury-related deaths. Hospitalizations where the intent of injury was unintentional, intentional (assault-related and self-inflicted injuries) and undetermined were included in analyses; injuries that resulted from therapeutic complications and their late effects were excluded. Data presented in this report provide information on hospitalizations, not individuals. For a complete listing of ICD-9-CM classification codes, see the Technical Appendix.4 2011 Child Fatality in New York City

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Classification of Injury Deaths Among Infants Younger Than One Year OldInformation on injury deaths among infants younger than one year old was obtained and abstracted usingthe same methodology as that for children one to 12 years old. Sleep-related injury deaths were identified forspecial review and defined as having occurred when environmental factors pertaining to sleep (e.g., position,location, sleep arrangement, and presence, type and location of bedding materials) were suspected or confirmedin the death of an infant. The deaths were classified as: • Unintentional suffocation or asphyxia if sufficient evidence was present (e.g., due to smothering or overlay). • Undetermined or unknown cause if there were no findings from the autopsy or post-mortem studies that pointed to a cause of death, but the death scene investigation revealed an environment that may have caused an injury, like asphyxia or suffocation.Based on these criteria, death resulting from unintentional threat to breathing (ICD-10 W75 and W84), anddeaths of undetermined intent (Y33-Y34) were included as sleep-related death. Using a structured abstractionform, details such as infant’s sleeping position and sleep surface were recorded from files maintained by theOCME for a five-year review from 2004 through 2008.ResultsInjury Deaths Among Children One to 12 Years OldCompared with the national rate, NYC has approximately 30% fewer deaths from all causes among childrenaged one to 12 years old. Nationwide, approximately 20 per 100,000 children die each year, compared withapproximately 14 per 100,000 in NYC. Most of this difference is due to fewer injury deaths in NYC (4 per100,000 NYC children vs. 8.7 per 100,000 children nationally). Still, injury deaths are the most commoncause of death in this age group both nationally and in NYC, with higher fatality rates than other leadingcauses of death, such as cancer, congenital malformations and other diseases.Figure 1. All Causes of Death Among Children (1-12 years), National vs. NYCFigure 1. All Causes of Death Among Children (1–12 years), National vs. NYC 10 National (2001-2007) 9 8.7 NYC (2001-2009) 8Deaths per 100,000 Children 7 6 5.0 5 4.0 3.9 4 3 2.4 2.4 2 1.7 1.7 1.2 1 1.0 0.9 0.7 0.3 0.2 0 Injury Cancer Congenital Influenza, Heart and Septicemia All Other Causes Malformations Pneumonia Cerebrovascular and Chronic disease Respiratory Disease Cause of DeathSource: Bureau of Vital Statistics, NYC DOHMH and Web-based Injury Statistics Query and Reporting System (WISQARS), Centers for Disease Controland Prevention. 2011 Child Fatality in New York City 5

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Nationally, most injury-related deaths among children aged one to 12 years are accidental or unintentional (82%, 7.1 deaths per 100,000 children), whereas 15% are homicides (1.2 deaths per 100,000 children). Compared with national statistics, NYC children experience less than half as many unintentional injury deaths (2.7 deaths per 100,000). This is mostly due to the difference in transportation-related fatalities (3.6 per 100,000 children nationally compared with 1.2 deaths per 100,000 children in NYC). NYC children also experienced fewer child homicides (0.9 deaths per 100,000 in NYC compared with 1.2 deaths per 100,000 nationally). National and NYC findings regarding other fatal injuries such as suicide are similar. Figure 2. Injury Deaths Among Children (1-12 years) by Manner of Death, National vs. NYC NYC Figure 2. Injury Deaths Among Children (1–12 years) by Intent of Injury, National vs. 8 National (2001-2007) 7.1 NYC (2001-2009) 7 6 Deaths per 100,000 Children 5 4 3 2.7 2 1.2 1 0.9 4.0 0.1 0.1 0.2 0.2 0.1 0.1 0 Accident Homicide Suicide Undetermined Therapeutic Complication Manner of Death Source: Bureau of Vital Statistics, NYC DOHMH and WISQARS, Centers for Disease Control and Prevention From 2001 to 2009, a total of 470 injury deaths occurred among NYC children aged one to 12 years old, accounting for 28% of all child deaths in NYC (n=1,681). Most injury-related deaths were unintentional (69%, n=324), including non-transportation (40%, n=190) and transportation accidents (29%, n=134). Twenty-four percent (24%, n=114) of injury deaths were due to intentional injuries including homicide (22%, n=104) and suicide (2%, n=10). Other injury deaths included undetermined deaths (6%, n=27) and cases of therapeutic complications (1%, n=5). The graph at the top of page 7 shows that child injury deaths varied slightly from year to year, with no discernible trend from 2001 to 2009. In 2001, a total of 79 deaths were observed, including 18 deaths due to a plane crash in Queens. From 2002 to 2008, injury deaths remained relatively stable, ranging from 47 to 56 deaths per year. In 2009, there were 31 child injury deaths, a decrease attributable to fewer non-transportation- related unintentional injuries and homicides. Specifically, three fire deaths occurred in 2009 compared with a range of five to 17 fire deaths per year from 2001 through 2008, and three homicides occurred compared with a range of seven to 23 homicides per year from 2001 to 2008.6 2011 Child Fatality in New York City

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Causes of Fatal Injuries Unintentional. Deaths that resulted from unintentional injuries comprised 69% (n=324) of the 470 injury- related child deaths between 2001 and 2009. Injuries resulting from blunt impact contributed to more than half (54%, n=175) of these deaths, including injuries sustained from a transportation accident (n=134), from a fall (n=32) or from being struck by a falling object (n=9), such as an unstable television or entertainment unit. Among the 134 deaths caused by transportation accidents, 87% (n=116) were motor vehicle-related and 13% (n=18) were due to a single airplane accident that occurred in Queens in 2001. Of motor vehicle-related accidents, the majority involved child pedestrians (76%, n=88), followed by child passengers (15%, n=17) and child cyclists (9%, n=11). The remaining unintentional injury deaths were caused by unsafe environments that produced the following: thermal injuries (27%, n=89), including fire (n=86), scald (n=2) and electrocution-related (n=1) injuries; suffocation or asphyxia (10%, n=33); drowning (4%, n=13); poisoning (2%, n=5); weapon (1%, n=3) and other causes (2%, n=6). Table 1. Causes of Unintentional Injury Deaths Among Children (1-12 years), NYC, 2001-2009, N=324. Cause N % Blunt Impact 175 54% - Transportation (motor vehicle and other transport) 134 41% - Fall 32 10% - Struck by falling object 9 3% Fire or burn 89 27% Suffocation/asphyxia 33 10% Drowning 13 4% Poisoning 5 2% Weapon 3 1% Other 6 2% Total 324 100% Source: Bureau of Vital Statistics, NYC DOHMH, OCME. Intentional. Deaths resulting from intentional injuries comprised 24% (n=114) of the 470 injury-related child deaths between 2001 and 2009. Most (91%) of these deaths were from homicide (n=104) and 9% were from suicide (n=10). Four specific causes made up 65% of child homicide deaths. Blunt impact or blunt force trauma was the most common cause (26%, n=27), followed by gunshot wounds (14%, n=15), fatal child abuse syndrome (13%, n=14) and smoke inhalation (12%, n=12). Among the 10 injury deaths certified as suicide, 80% were caused by hanging (n=8) and 20% were caused by overdose (n=2). Girls made up 70% (n=7) of suicides.10 2011 Child Fatality in New York City

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Table 2. Causes of Intentional Injury Deaths Among Children (1-12 years), NYC, 2001-2009, N=114 Cause N % Homicide Blunt impact 27 26% Gunshot 15 14% Fatal child abuse syndrome 14 13% Smoke inhalation 12 12% Stab wound 9 9% Smothering 5 5% Drowning 5 5% Shaking, whiplash and blunt impact 5 5% Poisoning (ingestion of toxic substance) 4 4% Scald burn 2 2% Hanging 1 1% Other 5 5% Total 104 100% Suicide Hanging 8 80% Overdose 2 20% Total 10 100%Source: Bureau of Vital Statistics, NYC DOHMH, OCME.Other. Between 2001 and 2009, 27 deaths (6% of all injury deaths) were certified as having an undeterminedmanner of death. The causes of these deaths included blunt impact injuries, drowning, scald burns, threatto breathing and medication overdose. In these cases, circumstances remained ambiguous or unexplainedfollowing post-mortem examination and death scene investigation. In addition, five children experiencedcomplications associated with medical treatment. These therapeutic complications were among children withpre-existing conditions and included self-extubation of tracheotomy tubing, entanglement in intravenoustubing and adverse effects of medication and treatment.Nonfatal InjuriesWhile fatal injuries signify more severe injuries, they represent just a fraction of the injury burden amongchildren. Nonfatal injuries are much more common and have many economic and social costs. Examinationof the larger burden of nonfatal injuries enhances development of prevention programming and policy. A briefsummary of injuries resulting in hospitalization is presented below.In NYC, nonfatal injuries are a leading cause of hospitalizations among children aged one to 12 years old.According to the most current data from NYC hospitals, between 2001 and 2008 there were 32,6811 injury-related hospitalizations among children, corresponding to an average of approximately 4,085 hospitalizationsannually. Most (95%) of these were due to unintentional injuries. On average, there were 3,895 hospital-izations due to unintentional injuries and 149 due to intentional injuries (122 assaults and 27 self-inflictedinjuries), annually. Self-inflicted injury hospitalizations include both self-harm and suicide attempts; the twosubtypes cannot be distinguished. On average, 40 injury hospitalizations annually were due to injuries ofundetermined intent.From 2001 to 2008, the rate of injury-related hospitalizations among children decreased 20% from 2001to 2008 (348 hospitalizations per 100,000 in 2001 to 279 per 100,000 in 2008). Most of this decline wasdue to decreases in unintentional injuries among children (333 hospitalizations in 2001, compared with 266per 100,000 in 2008). From 2001 to 2008, no discernible trend was seen with nonfatal intentional injury1 H ospitalizations where the intent of injury was unintentional, intentional and undetermined were included in analyses. 2011 Child Fatality in New York City 11

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hospitalizations. Child hospitalizations due to intentional assault ranged from 7 to 11 per 100,000; self- inflicted injuries ranged from 1 to 2 per 100,000; and injuries of undetermined intent varied from 2 to 4 per 100,000 children annually. Although the leading causes of injury for nonfatal injury hospitalizations and fatal injuries were similar, the precise rank and magnitude of their contributions differed. Falls were the leading cause of nonfatal unintentional injury hospitalizations among children, accounting for more then one third (34%, n=10,711) of injury hospitalizations between 2001 and 2008. Falls included falls from a height, falls from one level to another or on the same level, as well as slips, trips or stumbles. Motor vehicle and other transportation-related accidents were the next leading cause accounting for 16% (n=4,944) of all unintentional injury hospitalizations among children, most of these involved pedestrian injury. Injuries from fire or burn were the third leading contributor to unintentional injury hospitalizations, accounting for 14% (n=4,374) of unintentional injury hospitalizations among children; most of these involved hot substances. Data for these and other causes of nonfatal child hospitalization from unintentional injuries are presented in Table 3. Table 3. Causes of Nonfatal Unintentional Injury Hospitalizations Among Children (1-12 years), NYC, 2001-2008, N=31,163 Cause N % Falls 10711 34% Motor vehicle (MV) traffic and other transportation 4944 16% - MV - pedestrian 2827 9% - MV - occupant 579 2% - MV - pedal cyclist 363 1% - MV - other/unspecified 122 1% - Other transportation - pedal cyclist 777 2% - Other transportation - other 276 1% Fire or burn 4374 14% - Hot substance 4023 13% - Fire/flame 351 1% Poisoning 2255 7% Natural/environmental 2055 7% Struck 1709 5% Cut 869 3% Suffocation 267 1% Machinery 72 1% Drowning 68 1% Firearm 24 1% Other/unspecified 3815 12% Total 31163 100% Source: Statewide Planning and Research Cooperative System New York Sate (NYS) DOH, updated December 2009.12 2011 Child Fatality in New York City

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Special Section: Sleep-Related Injury Deaths Among Infants Younger Than One Year Old While the NYC CFRT is mandated to review injury deaths among children aged one to 12 years old, for this report committee members also elected to review infant injury deaths (from birth up to 12 months) to highlight the main causes of preventable death among NYC’s youngest children. From 2004 to 2008, perinatal conditions, congenital malformations, and short gestation or low birth-weight were the leading causes of infant deaths in New York City. These conditions have multiple, complex causes. Data show injury as the fourth leading cause of death among infants younger than one year old, accounting for 9% (n=325) of all infant deaths (n=3,626) and corresponding to a rate of 58.9 deaths per 100,000 infants. Infant injury deaths resulted from unintentional injuries (22%, n=70), intentional injuries (14%, n=44), injuries of undetermined intent (64%, n=209) and therapeutic complications (1%, n=2). Figure 9. Leading Causes of Infant Deaths, NYC, 2004-2008, N=3,626 Figure 9. Leading Causes of Infant Deaths, NYC, 2004-2008, N=3,626 35 32% 30 Percent of Infant Deaths 25 20% 20 15% 15 10 9% 9% 6% 5 2% 2% 1% 1% 1% 0 Perinatal Congenital Short Injury Respiratory Sepsis Cardio- SIDS Other Disease All other conditions malformations gestation/ distress vascular respiratory of nervous LBW disorder* conditions** system Cause of death SIDS = sudden infant death syndrome, LBW = low birth weight *Includes heart disease, cerebrovascular disease and other cardiovascular diseases. **Includes influenza/pneumonia, chronic lower respiratory disease and pneumonitis. Source: Bureau of Vital Statistics, NYC DOHMH. Sleep-Related Infant Injury Deaths Explained Sleep-related death is the name for a grouping of infant deaths caused by both injury (unintentional suffocation in bed and undetermined causes) and by sudden infant death syndrome (SIDS). In NYC, more than three quarters (78%, n=252) of infant injury deaths between 2004 and 2008 were identified as having unsafe sleep conditions and environments.2 Sleep-related injury deaths include unintentional suffocation in bed and sleep-related injuries of undetermined manner. These deaths are related to sleep when an infant was last seen asleep and when environmental factors related to sleep (e.g., position, excess bedding, bed-sharing or sleep surface) were present and may have contributed or been associated with the death. Some sleep-related infant deaths are not caused by injury, but instead are caused by SIDS, a term that has long been used to categorize sleep-related infant deaths where a cause cannot be found. SIDS is a category of sleep- related deaths thought to be due to natural diseases. 2 See Appendix for breakdown of non sleep-related infant injury deaths.14 2011 Child Fatality in New York City

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In NYC, the criteria to certify a death as SIDS narrowed in 2004, resulting in more sleep-related deaths being classified as unintentional suffocation in bed or having an undetermined cause of death. The graph below depicts the diagnostic coding shift of sleep-related infant deaths in NYC over time. The majority of sleep- related deaths identified in recent years (2004 to 2008) were not due to SIDS, as in years prior. Rather, the majority of sleep-related deaths since 2004 were classified as unintentional suffocation in bed and injuries of undetermined intent, resulting in a rise from 9.6 deaths per 100,000 infants in 2000 to 43.9 deaths per 100,000 infants in 2008. This shift reflects injury-related findings at death scene investigation that point towards unsafe sleep environment. Figure 10. Trends in in Sleep-related Infant InjuryInjury Deaths, NYC, 2000-2008 Figure 10. Trends Sleep-Related Infant (1 year) Deaths, NYC, 2000-2008 SIDS 70 Sleep-related injury All sleep-related deaths (SIDS sleep related injury) 60 Deaths per 100,000 NYC Infants 50 40 30 20 10 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 Years Source: Bureau of Maternal and Infant Reproductive Health, NYC DOHMH, Bureau of Vital Statistics, NYC DOHMH, OCME. Demographics of Sleep-Related Infant Injury Deaths Infant age at death. Between 2004 and 2008, 74% (186 of 252 infant deaths) of sleep-related infant injury deaths occurred when the infant was from 28 days to four months of age. Deaths among infants younger than 28 days old (10%, n=25) and among infants five to 12 months old (16%, n=41) were less frequent.Figure 11. Sleep-Related Infant (1 year) Injury Deaths by Age at Death, NYC, 2004-2008, N=252 Figure 11. Sleep-Related Infant (1 year) Injury Deaths by Age at Death, NYC, 2004-2008, N=252 28 days 10% 5–12 months 28 days – 4 months 16% 74% Source: Bureau of Maternal and Infant Reproductive Health, NYC DOHMH, OCME. 2011 Child Fatality in New York City 15

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Figure 5. Injury Deaths Among Children (1–12 years) by Age Group, NYC, 2001-2009, N=470Borough of residence. Bronx infants experienced the highest rate of sleep-related injury deaths, with59.8 deaths per 100,000 infants, followed by Brooklyn infants (46.1 per 100,000), Staten Island infants(44.2 per 100,000) and Manhattan infants (41.5 per 100,000). Queens infants had the lowest rate, with30.8 sleep-related injury deaths per 100,000.Figure 14. Sleep-Related Infant (1 year) Injury Deaths by Borough of Residence, NYC, 2004-2008, N=252* Rate 59.8 60Deaths per 100,000 NYC Infants 50 Rate 46.1 Rate 44.2 Rate 41.5 40 Rate 30.8 30 20 10 0 Bronx Brooklyn Staten Island Manhattan Queens Borough of Residence*A small proportion (4%, n=10) of sleep-related injury deaths in NYC occurred among infants residing outside of NYC.Source: Bureau of Maternal and Infant Reproductive Health, NYC DOHMH, OCME.Case Review of Sleep-Related Infant Injury DeathsAn in-depth review of all 252 sleep-related infant injury deaths occurring between 2004 and 2008 wasconducted (21% unintentional suffocation deaths, 79% undetermined deaths). These deaths involvedcircumstances in which an infant died during sleep or could be linked to some potentially unsafe sleep-related environmental factor. Information from the OCME revealed that the risk factors for thesesleep-related injury deaths included infant sleep position and sleep environment, such as sleep surface,excess bedding and bed-sharing with an adult or another child.Sleep position. A review of sleep position showed that 57% of infants who died of sleep-related injurywere found either on their stomachs (42%, n=105) or on their side (15%, n=39), in a crib or bassinet.These positions are known to be unsafe infant sleeping positions; positioning infants on their backs isconsidered safer. Sixteen percent (16%, n=40) of infants were found in other positions or locations, suchas in a stroller, carrier, sling or being held by a sleeping adult. 2011 Child Fatality in New York City 17

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Figure 15. Sleep-related Infant (1 year) Injury Deaths by Sleep Position When Found, NYC, 2004-2008, N=252 Figure 15. Sleep-Related Infant (1 year) Injury Deaths by Sleep Position When Found, NYC, 2004-2008, N=252 Other 16% Stomach 42% Unsafe Sleep Position in Bed 57% Back 27% Side 15% Source: Bureau of Maternal, Infant and Reproductive Health, NYC DOHMH, OCME. Bed-sharing. A review of bed-sharing showed that 63% (n=160) of infants who died of sleep-related injuries were found sharing a bed with another sleeper, a situation known to be unsafe. For infants, sleeping alone is safer than bed-sharing. Bed-sharing typically involved an infant sharing a bed with a parent or other adult (n=123); however several deaths involved bed-sharing with another child (n=10), such as a sibling, or with another child and an adult (n=25). For example, in one instance an infant girl died of unintentional suffocation while bed-sharing with her twin brother. No bed-sharing occurred in 35% (n=89) of cases, and the occurrence of bed-sharing was unknown in 2% (n=5) of cases. Figure 16. Sleep-related Infant (1 year) Injury Deaths by Bed-sharing, NYC, 2004-2008, N=252 Figure 16. Sleep-Related Infant (1 year) Injury Deaths by Bed-sharing, NYC, 2004-2008, N=252 Unknown 2% Bed-sharing with at least 1 adult 49% No bed-sharing 35% Bed-sharing (Unsafe Sleep Environment) 63% Bed-sharing with both adult and child 10% Bed-sharing with at least 1 other child 4% Source: Bureau of Maternal, Infant and Reproductive Health, NYC DOHMH, OCME. Sleep surface. The sleep surface and location of death was also considered. More than three quarters of infants (76%, n=191) who died from sleep-related injuries were found sleeping in an adult bed, couch, stroller, car seat or other environment known to be unsafe. Sleeping alone and on the infant’s back in a crib or bassinet is known to be safest for infants. In some instances, the infant was moved from a safe crib or bassinet where he or she had been sleeping to a less safe sleep environment. For example, an infant girl was taken out of her bassinet because she was crying. Her father picked her up and held her on the couch until they both fell asleep. He later awoke and found that he was positioned on top of her.18 2011 Child Fatality in New York City

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Figure 17. Sleep-related Infant (1 year) Injury Deaths by Sleep Surface, NYC, 2004-2008, N=252 Figure 17. Sleep-Related Infant (1 year) Injury Deaths by Sleep Surface, NYC, 2004-2008, N=252 Unknown 1% Crib / Bassinet 23% Adult bed 62% Sleep Surface (Unsafe Sleep Environment) 76% Other (Stroller, car seat, floor, etc.) 7% Couch / Sofa 7% Source: Bureau of Maternal, Infant and Reproductive Health, NYC DOHMH, OCME. Bedding. The presence of excess bedding – defined as more than one bed sheet and one blanket – was found in almost two thirds (64%, n=162) of suffocation and undetermined deaths. Examples of excess bedding include pillows, comforters, quilts, crib-bumpers and towels, all of which are unsafe for infants.Figure Figure 18. Sleep-Related Infant (1 year) Injury Deaths by Presence of Excess Bedding, NYC, 2004-2008, 18. Sleep-related Infant (1 year) Injury Deaths by Presence of Excess Bedding, NYC, 2004-2008, N=252 N=252 Unknown or N/A 20% Excess bedding 64% Bedding (Unsafe Sleep Environment) 64% No excess bedding 16% Source: Bureau of Maternal and Reproductive Health, NYC DOHMH, OCME. Season. Though excess bedding was found in the majority of sleep-related infant injury deaths, these deaths did not vary by season. Overall, 28% (n=71) of infants died in the winter; 24% (n=60) died in the spring; 23% (n=59) died in the summer, and 25% (n=62) died in the fall. These findings suggest that excess bedding may not be related to seasonality, as common articles of bedding considered to be unsafe, such as pillows and crib bumpers, are often present in an infant’s sleep environment year-round. Overall, the majority of sleep-related injury deaths involved modifiable risk factors such as bed-sharing, sleep positioning, sleep surface, and excess bedding. These risk factors are not mutually exclusive; many of the infant deaths involved more than one sleep-related risk factor. In summary, more than three quarters (78%) of infant injury deaths identified unsafe sleep conditions or environments. Of these deaths, more than half involved at least one modifiable, sleep-related risk factor. 2011 Child Fatality in New York City 19

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Summary Injury Deaths Among Children This 2011 report of the NYC CFRT presents an aggregate review of the 470 injury deaths that occurred among NYC children aged one to 12 years old from 2001 to 2009. Although they occur at less than half the rate of the national average, fatal child injuries are still a significant problem in NYC. A review of the data shows that injury deaths accounted for 28% of all child deaths in NYC children aged one to 12 years old. Data also show an unequal burden of fatal injuries among NYC children, with higher injury death rates found among younger aged children, boys and black, non-Hispanic children. Data show that deaths among children were more likely to occur from unintentional injuries than from intentional injuries (69% vs. 24%, respectively). Unintentional motor vehicle traffic accidents contributed the most to child injury deaths in NYC overall (25%), with more than three quarters of deaths occurring among pedestrians. Also, fires or burns contributed to 22% of all child deaths in NYC. Intentional injuries accounted for 24% of all child injury deaths, nearly all of them (91%) were homicides. Although the number of fatal child injuries among children aged one to 12 years old has remained stable in recent years, a marked decrease was seen from 2008 to 2009 (51 deaths in 2008 vs. 31 deaths in 2009). This decrease was attributable to fewer unintentional non-transportation injuries and homicides. It is not clear whether this improvement reflects a trend. Nonfatal Child Injuries Serious, nonfatal injuries among children occur with much greater frequency than fatal injuries. While nonfatal injuries among children aged one to 12 occurred more frequently than fatal injuries, the leading causes of injury hospitalization are similar to the leading causes of injury death. On average there were about 3,900 nonfatal unintentional injury hospitalizations annually, and the leading causes of nonfatal unintentional injury hospitalization among children were falls, burns and motor vehicle-related accidents. Also on average there were about 150 nonfatal intentional injury hospitalizations annually. Leading causes of intentional injury hospitalizations were assault-related child abuse and physical force. Reviewing nonfatal child injuries in combination with fatal injuries provides a more comprehensive story of the substantial burden of severe injuries affecting NYC children. Injury Deaths Among Infants This year’s report was expanded to include information on the causes and circumstances of infant deaths. Injury is also a leading cause of death among NYC children younger than one year old, with more than three quarters (78 %) of infant injury deaths related to unsafe sleeping conditions and environments. These sleep-related deaths included unintentional suffocation in bed and sleep-related deaths of undetermined manner. These deaths involve circumstances in which an infant died during sleep or could be linked to a potentially unsafe sleep environment, such as unsafe sleeping position or sleep surface, the presence of excess bedding or the practice of bed-sharing. Infants at highest risk for sleep-related infant injury deaths were between the ages of 28 days and 4 months old and were black, non-Hispanic. Data presented in this report should be used to raise awareness among parents and caregivers about the importance of safe sleep environments.20 2011 Child Fatality in New York City

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Limitations and StrengthsThis retrospective review of child injury deaths has some important limitations. Some characteristics thatmay have been related to risk for an injury were not formally captured in case files, such as level of parentalor guardian supervision and other family conditions or stressors. These factors, particularly for certain ages ofchildren, may play a role in mitigating dangerous circumstances.Similarly, hospitalization discharge data represent an important and useful data source for general surveillanceof nonfatal child injuries. They are accessible, and enable epidemiologic descriptions of the children hospital-ized for injuries. However, interpretation of discharge data presents certain difficulties. Hospitalization recordsreflect an event, and some children with injuries may be hospitalized more than once in any given year. Thismay result in a slight overestimate of the counts and rates of children injured. Further, some data elements aresubject to incompleteness or lack of uniformity or both. Because data on the race and ethnicity of individualpatients in hospitalization records are not collected in a standard manner across hospitals, we do not comparehospitalization rates by race and ethnicity. Similarly, the manner in which injury codes are selected acrosshospitalizations also may vary, and must be interpreted with caution. 2011 Child Fatality in New York City 21

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Recommendations Injuries are a leading cause of death among infants and children in NYC. Based on report findings, the CFRT identified key recommendations to make the physical and social environment safer for NYC children. The following are action steps for policymakers, parents and caregivers and service providers in addressing common childhood injuries identified in CFRT annual reports. In addition, the report includes an information sheet on safe sleep for infants, and a tip sheet for parents and caregivers to prevent injuries in the home. Policymakers can promote safer environments to reduce the risk of injury among children. • Increase child safety through enforcement of existing laws and regulations. Specifically: – Children up to age seven must be properly restrained in a child safety or booster seat, depending on the height and weight of the child, when riding in a motor vehicle. – Owners of multiple dwellings buildings must: • Install smoke detectors in all occupied apartments and carbon monoxide detecting devices within proximity of bedrooms. • Install approved window guards in homes where a child under age 11 resides and in public areas if a child under age 11 lives in the building. – Retailers must not sell drop-side cribs. • Support current proposals and new legislation focused on increasing child safety. Specifically: – Hospitals should provide education to new parents on infant safe sleep and help parents obtain resources, such as cribs, if they do not have one. – Child safety seats should have labels outlining compatibility with different types of automobiles. – Large trucks, tractors and tractor-trailers or semitrailers should have convex mirrors to increase drivers’ range of view. – peed cameras should be installed along dangerous streets to reduce serious injuries and fatalities S caused by speeding vehicles. – Children should be properly restrained in motor vehicles in accordance with best-practices endorsed by the American Academy of Pediatrics. Parents and guardians should slow the transition from a rear-facing child safety seat, to forward-facing seat to a booster seat. Children younger than 13 years of age should be restrained in the rear seats of vehicles. – Landlords should set tap water at a safe temperature – a maximum of 120 degrees Fahrenheit – for all dwelling units to prevent scald burns. • dvocate for increased detail in systematic, uniform diagnostic coding standards for recording injury A characteristics in official documentation of injury deaths and hospitalizations. Parents and caregivers should watch children closely, learn about safety risks and create a safe home and play environment. • Practice safe-sleep for infants. See tips sheet on page 24. • afeguard your home with devices like window guards, safety gates at stairs and other dangerous places, S safety latches for drawers and cabinets, electrical outlet covers and smoke and carbon monoxide detectors. Keep medicines, cleaning products and matches out of the reach of children. See checklist for preventing child injuries in the home on page 26. • Supervise young children closely. Choose caregivers carefully and discuss safety thoroughly with them. • upervise your children while crossing the street. Children under age 10 should only cross the street S with a responsible adult and assess children’s readiness to cross the street alone. Tell and show children to always look left, then right, then left again before crossing the street. Talk to your children about important traffic signs and signals.22 2011 Child Fatality in New York City

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• ecure children riding in cars with seat belts or place them in a car seat or booster seat S (depending on the age and weight of the child). • each your children about safety while at play; be sure they wear helmets and other protective gear T whenever they are on wheels (e.g., bicycles, skates, skateboards and scooters). • Get help: – aintain positive parent-child interactions. When the stresses of parenting are overwhelming call the M 24-hour Prevention and Parent Helpline 1-800-CHILDREN (1-800-244-5373) for support. – f you do not feel safe in your relationship or if you feel that stresses in your relationship compromise I your parenting, call 24-hour Domestic Violence Hotline (1-800-621-HOPE). – Call 311 for information on housing-related safety issues and child services around the City.Health care and other providers should screen for safety risks, document cases of injury intheir records and support parents and caregivers in their efforts to safeguard their homes. • Inquire about and document all information when a child presents with an injury. • Counsel parents about safeguarding their homes to prevent child injuries. • ounsel parents about the need for appropriate supervision, based on child’s age, development and C exposure to possible hazards. Children need close supervision when at play indoors and outdoors, while crossing streets and in and around motor vehicles. Provide information about choosing appropriate caregivers. • ounsel expectant and new parents on infant safe-sleep practices and utilize every opportunity to visually C demonstrate safe sleep practices for parents and other care givers. • Report all poisonings, window falls and drownings to the DOHMH by calling 311. • ook for early signs of abuse and report all suspected child abuse and neglect to the New York State L Central Register of Child Abuse and Maltreatment (1-800-342-3720). All health care providers are mandated reporters. Never assume someone else is going to report it. • dvise parents to call 311 for information on housing-related safety issues and child services around A the City. • efer to the American Academy of Pediatrics website for additional information and safety tips. R www.aap.org/family/tippmain.htmFor City agency activities that target child injury prevention, refer to previous CFRT reportshttp://www.nyc.gov/html/doh/html/ip/ip-index.shtml 2011 Child Fatality in New York City 23